Help Me With This Case Questionnaire

This form is designed to help you provide our team with a thorough review of your case and support you in managing complex or challenging cases more effectively. Please ensure that all relevant information is included and that any requested documents are uploaded. This will help our team gain a clear understanding of the patient’s clinical and microbiological presentation.

Our clinical team will review your submitted information and provide recommendations within 5 business days. For further assistance, please email contact@wellnessdentistrynetwork.com

Patient's first name & last initial(Required)

Patient's age(Required)

Patient Sex at Birth

Diagnostic Information

Please list any medical conditions and associated medications/supplements that the patient takes(Required)

What other periodontal disease risk factors did the patient have?(Required)

Family history of periodontal disease

Family history of cardiovascular disease

Family history of cancer

Diabetes

History of smoking or vaping

None reported

What is their relationship to the patient? (Mother, Father, Self, etc.)(Required)

Patients with a family history of cardiovascular disease, cancer, or periodontal disease may have a genetic predisposition to periodontal disease development and progression. Please list actual diagnosis (cancer type, CVD diagnosis, etc) if applicable.

Do you know the patient's HbA1c?(Required)

Uncontrolled diabetes (HbA1c > 7%) is a Grade modifier which can exacerbate the progression of periodontal disease.

How long has the patient been in smoking and/or vaping?(Required)

Approximately how many times a day does the patient smoke and/or vape?(Required)

Smoking frequency (≥ 10 cigarettes / vaping a day) is a Grade modifier which can exacerbate the progression of periodontal disease.

Is the patient in a relationship involving close physical contact, such as kissing or sharing utensils?(Required)

Yes

Do you know the microbiological makeup or periodontal status of this person?(Required)

The transmissibility of pathogens can occur easily between partners or through sharing utensils and can affect the microbiological makeup of your patient, making the disease potentially harder to treat.

Yes

Does the patient have a history of the following conditions(Required)

History of viral expression (frequent cold sores, herpes, aphthous ulcers in stressful conditions, etc)

History of yeast infections (chronic sinusitis, vagina yeast infections, gut/digestive issues, thrush, etc)

None reported

Please verify what radiographs are being sent.(Required)

Please verify that file is labeled correctly with the date taken and being uploaded and sent

FMX

BWX / VBWX

Panoramic

None

Was a Risk Modifier Form completed?(Required)

Please verify that file is labeled correctly and being uploaded and sent

Yes

Please verify that pre/post-treatment PERIODONTAL CHART is being sent.(Required)

Please verify that the periodontal charts are labeled correctly with date and appointment type (e.g., disease diagnosis, 8-week repetitive biofilm therapy retest, etc)

Yes

What type of bleeding is the hygiene team charting?(Required)

See Papilla Bleeding Index in 2. GUM DISEASE module in WDN library

Please verify that pre/post-treatment SALIVARY DIAGNOSTIC TEST are being sent.(Required)

Please verify that file is labeled correctly with the date taken and being uploaded and sent

Yes

Prescription & Host Modulation Strategies

Please select any prescriptions that were prescribed to the patient.(Required)

Antiviral

Antibiotics

Antifungal

None prescribed

Was antiviral therapy completed prior to SRP?(Required)

Current research indicates that viral treatment should begin 10 days prior to SRP and be completed by the day of SRP.

Yes

No, it was started day of SRP

No, it was started at a subsequent appointment

For antivirals, please provide what antiviral therapy were prescribed and the duration.(Required)

If antibiotic therapy was indicated, did the patient begin antibiotic therapy the day of SRP?(Required)

Current research indicates that antibiotic treatment should begin on the day of SRP (if completed in one appointment) or on the final SRP appointment for best results.

Yes

For antibiotics, please provide what antibiotic(s) were prescribed and the duration(Required)

If antibiotic(s) were used, were probiotics also prescribed to manage gut health?(Required)

Yes

Please provide the name of the probiotic prescribed.(Required)

If antifungal therapy was indicated, did the patient begin antifungal therapy the day of SRP?(Required)

Yes

For antifungals, please provide what antifungal(s) were prescribed and the duration(Required)

Was a host modulation strategy used?(Required)

Low-dose doxycycline (20mg)

Sleep analysis

Probiotics/prebiotics

Dietary supplementation

Nitric oxide supplementation

Smoking cessation

Ozone therapy

Perio Protect trays

None

Other, please list below

Please list any product names used as host modulatory strategies.(Required)

Product names can include probiotic, prebiotics, types of supplements (e.g. vitamins, minerals, etc.), sleep study (e.g., home sleep apnea tests, WatchPat, HRPO, etc)

Other Host Modulation Strategies(Required)

Daily Disease Regimen

During active therapy, what rinses were prescribed for the patient along with the instructions for use?(Required)

Please list what rinses were prescribed along with any instructions dispensed to the patient for use (e.g., how many times per day, how long to rinse for, etc)

During active therapy, what interproximal aids were prescribed for the patient along with the instructions for use?(Required)

Please list what interproximal aids were prescribed along with any instructions dispensed to the patient for use (e.g., how many times per day, any additives in the water flosser, amount of additive, etc)

During active therapy, what toothpaste(s) were prescribed for the patient along with the instructions for use?(Required)

Please list what toothpaste(s) were prescribed along with any instructions dispensed to the patient for use (e.g., how many times per day, etc)

Any Additional Information Not Previously Covered?

Your Information

Practice Name(Required)

Role(Required)

Name(Required)

First Last

Email(Required)

Phone(Required)

Upload All Files Here

Please upload all medical/dental history, periodontal charts, radiographs, salivary diagnostic tests, Risk Modifier form, Daily Disease Regimen form, and any other pertinent information that may help our clinical team evaluate your case.

Drop files here or

Accepted file types: jpg, png, pdf, zip, Max. file size: 2 GB.

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